Dr. Julie A.

Griffith
Pediatric Neurology
120 Ross Valley Drive
San Rafael, CA 94901
(415) 925-1616
Fax (415) 259-4011
e-mail:mybrainhealth@comcast.net
www.Mybrainhealth.org

Neurological History and Physical

Patient’s name: __________________________________Date of birth:______________________________________

Date of examination: ______________________________

Referring practitioner: __________________________

Address:______________________________City, State, Zip Code __________________________________________

Phone number (___) _______________

Mother’s name ________________________________Father’s name _______________________________________

Legal guardian’s name (if different than above) ___________________________________

How did you find out about us or who referred you to this practice? ____________________________________________
_______________________________________________________

Identification: ______________ (nickname, if has one) is a right/left handed/ambidextrous __________ grade

____________yr ______mo old boy/girl referred for evaluation of _______________________________________

__________________________________________________________________
__________________________________________________________________
______________________________________
History of present illness:

Pediatric Neuro H & P 1 12/28/10

Past medical history:
Pregnancy: medical problems during pregnancy: _______________________________
medications taken during pregnancy: _______________________________
tobacco, alcohol, cocaine, other drugs of abuse: _______________________
gestation _______wks, (full term is 40 wks) _________________________

Labor: ______hrs, artificial/spontaneous rupture of membranes

Delivery: ______birth wt, ______ cm head circumference
childbirth was vaginal /induced/ by C-section
meconium (stool in amniotic fluid) yes/ no
vertex (head down, face back), or face up (occiput posterior)/ breech
heart rate abnormalities during delivery Yes/No
Neonatal: Difficulties feeding/suck/swallow Yes/No
Colicky/irritable infant Yes/No

Past neurologic history:

Headaches Yes/No If yes, describe: ______________________________
Significant head trauma Yes/No If yes, loss of consciousness? vomiting? lethargy?
____________________________________________
Seizures Yes/No
Meningitis Yes/No

Developmental history:
Bowel training Completed Yes/No By what age
Bladder training Completed Yes/No By what age

Please give ages in months or years when these milestones were acquired (as best approximated):
Motor
Gross ventral push up ____, sit _____, stand ______, walk _____, run ____
runs alternating feet up stairs without holding rail _____, tricycle _____
bicycle without training wheels ______ ,
frequent falls/clumsiness ______________
Fine reaching ____, hand-to-hand ______, pincer _____, drawing _____
scissors ______. Quality of handwriting: _________
Language cooing _______, babbling ______, 1st word by ______mos/yrs,
2 wds together ( noun/verb) _______, # word vocabulary by 2 yrs ______,
age when clearly understood by strangers _____________, lisp ______
difficulties with drooling/handling secretions or in swallowing food
________________________________
Social good eye contact ___________, appreciates affection/hugs __________
understands social cues of interaction appropriate for age Yes/No _____
aggressive? (bite/kick/hit, getting into fights) ____________,
plays with children younger/same age/only much older or adults ________

Therapy received in past or currently getting:

Occupational ____ times/wk, ___hrs/session, by whom ________, where _______,
began _____________, issues now covering _____________________
Physical ____ times/wk, ___hrs/session, by whom ________, where _______,
began _____________, issues now covering _____________________
Speech ____ times/wk, ___hrs/session, by whom ________, where _______,
began _____________, issues now covering _____________________

Past medical history, Medical Problems:

1) ________________ Date onset __________ Date resolved___________ treatment __________
2) ________________ Date onset __________ Date resolved___________ treatment __________

Pediatric Neuro H & P 2 12/28/10

 3) ________________ Date onset __________ Date resolved___________ treatment __________

Hospitalizations: for what _______________________________, when ______________

__________________________________________________________

Surgeries: ______________________________________, when ______________

Medications: name of drug ______________, dosage (mg)________, # times/day ____

name of drug ______________, dosage (mg)________, # times/day ____

name of drug ______________, dosage (mg)________, # times/day ____

Allergies to medications: ____________________, what happened to body __________________

Review of systems:
Dermatologic: white, brown or red birthmarks _________________________________

Endocrine: heat or cold sensitive, hair thinning/falling out, dry skin _____________

ENT: ear aches, problems with hearing _______________________________

Genito: abnormal development of genitalia:_____________________________

precocious puberty or abnormal menses:_________________________
difficulty with erection or ejaculation: _________________________
any concern of sexual abuse: _________________________________
Gastrointestinal: difficulties with swallowing/appetite/eating problems _______________
failure to thrive/obesity ______________________________________
stomach upset, belly pains, blood in stools _______________________
Heme: easy bruising or bleeding after injury ___________________________

Immunologic: frequent infections (pneumonias, urinary tract infections, many

ear infections, sinusitis) _____________________________________
any risk of HIV? (blood transfusion, IV drug abuse in parents or
known exposure of parents?) _________________________________
sexually active ___________________________________________
Neuro: difficulties with attention _____, hyperactivity ____, impulsiveness__
balance/coordination problems ______________________________
conduct difficulties _______________________________________
excessive fatigue/taking naps during the day ____________________
muscle aching/cramping/twitching or fasciculating muscles,
muscle weakness________________________________________
oppositional/defiant symptoms________
sleeping difficulties _______________________________________
unusual spells or behavior not mentioned anywhere above _________

Oncologic: unexplained weight loss, failure to thrive, fatigue

Orthopedic: significant accidents or traumas, bone aches, frequent fractures,

scoliosis or abnormal back curvature _________________________
Psychiatric: emotionally labile, weepy, sad, depressed, unusual behavior
any concern of physical abuse ______________________________
Ophthalmologic: difficulty with vision or with eye movements ___________________
Urinary: urinary urgency, frequency or new incontinence, bedtime enuresis

Pediatric Neuro H & P 3 12/28/10

Other: ________________________________________________________

Educational history: Difficulties now? Yes /No If yes, please complete the following:

Schools in chronologic order:

Name of school age difficulties type of help given name of teacher #stud / # teachers
____________ ____ ____________ ___________________ _____________ _____________
____________ ____ ____________ ___________________ _____________
____________ ____ ____________ ___________________ _____________
____________ ____ ____________ ___________________ _____________
____________ ____ ____________ ___________________ _____________
____________ ____ ____________ ___________________ _____________

Family history: (please ask each biologic parent, even grandparents)

Abnormal anatomy of any body parts ______________________________________________________
Autoimmune disorder (lupus, diabetes mellitus, colitis, rheumatoid arthritis, other ) __________________
Birthmarks (white, red, brown) ___________________________________________________________
Genetic syndromes ___________________________________________________________
Grey hair, prematurely by the 30’s ________________________________________________________
Headaches or migraines ________________________________________________________________
Head size, unusually large or small _______________________________________________________
Learning difficulties (held back in school a year, dyslexia, math problems) _________________________
Left-handedness or ambidexterity _________________________________________________________
Mental retardation _____________________________________________________________________
Miscarriages/stillbirths, sudden infant death syndrome ________________________________________
Neurologic disease (multiple sclerosis, other) ________________________________________________
Seizures _____________________________________________________________________________
Early stroke or heart attack (before or at 55 yrs of age) _________________________________________

other diseases that run in the family _______________________________________________________

Social history:
Biologic parents are married/ living together/divorced/separated. There are _____ children.
Child’s name age
__________ _____
__________ _____
__________ _____
Mother’s occupation: _________________________________
Father’s occupation: _________________________________

Significant psychologic stressors include

__________________________________________________________________________________________________________
__________________________________________________________________
__________________________________________________________________
_________________

Pediatric Neuro H & P 4 12/28/10

Physical examination: (for doctor to fill out):
HC ( ) ( %); Ht ( ) cm, ( %); wt ( kg), ( %)
lying BP HR standing BP HR

General: ________________________________________________________________

HEENT: _____ eyes, _________ ears, ______ palate, ________skull, ____ant font,
___sutures, _____skull shape, ____ teeth
CV: ___ S1, S2, __ murmurs, gallops or rubs; ___cranial bruits
abd: _____ liver; ____ spleen
GU: ____ Tanner
derm: ____ neurocutaneous stigmata; hair: quality, hairline, whorls; nails
vertebrae/sacrum ____
ext: ____

Neurologic: MSE: attention:

language: ___naming, ___repetition, ___diadochokinesis ___writing , ___reading,
memory: auditory, verbal : /3 encoding, /3 regist, /3 at 5 minutes
visual-wd, shape: /3, sequence, wd shape
affect:
level of motor activity:
abstraction:
clock:
construction:
cn: ___/20 OD; ___/20 OS; ___ optic nerve, ___retinae, II- XII ___
motor: /5 throughout drift
gait: spontaneous: _____, ____toe, ____heel
sensory: Romberg:
face UE LE
LT ____ _____ _____
pin ____ _____ _____
cold ____ _____ _____

Labs/studies:

Head MRI:

EEG:

Pediatric Neuro H & P 5 12/28/10

Impression:
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
___________________________________________________________________

Assessment:
1)____________________________________________________________________________
2)____________________________________________________________________________
3)____________________________________________________________________________

Plan:
1)___________________________________________________________________________
2)___________________________________________________________________________
3)___________________________________________________________________________
4)___________________________________________________________________________
5)___________________________________________________________________________
6)___________________________________________________________________________
7)___________________________________________________________________________

Thank you for referring _______________________________ to my office. If you have any questions or suggestions,
please feel free to call me at (415) 925-1616.

Respectfully,

Julie A. Griffith, M.D., M.S., C.M.T.

Neurology

Julie A. Griffith, M.D., M.S., C.M.T.

120 Ross Valley Drive
San Rafael, CA 94901
Phone (415) 925-1616
Fax (415) 259-4011

Pediatric Neuro H & P 6 12/28/10

CONFIDENTIAL SECTION:

Drug abuse:
Circle if prenatal use or use during pregnancy, current use, in the past use
alcohol use _________________________________
Amount of use, drink of choice, amount/day or week or month, number of
years drunk, ______________________________________________
Cocaine, heroine, marijuana, metamphetamines __________________________
Other drugs of abuse _____________________________________________
tobacco # of packs/day, # years smoked ______________________________

HIV testing: Testing: _______________

Treatment: ____________________________

Psychiatric: symptoms____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
Diagnoses: ___________________________________________________________________________
___________________________________________________________________________

Treatment ___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________

Family history of :

HIV positivity: _______________________________________________________________________

Drug abuse: _______________________________________________________________________
_______________________________________________________________________
Psychiatric symptoms or diagnoses: _______________________________________________________
________________________________________________________________________

Pediatric Neuro H & P 7 12/28/10